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Stuttering: An RFP for a cultural perspective
J. FLUENCY DlSORD. 14 (1989) 67-77
STUTTERING: AN RFP FOR A CULTURAL PERSPECTIVE GEORGE H. SHAMES University of Pittsburgh Stuttering has been the target of much attention from theorists and researchers as well as from clinicians. As a result, a large body of literature exists about its etiology, psychologic and physical properties, patterns of occurrence, measurement, and evaluation and management. In the United States, the overwhelming majority of data come from experiences with stutterers who are in the majority of mainstream America. Much of these data could vary across cultures and across languages. For minority group stutterers who live in diverse cultural and linguistic environments, there may be different burdens and stress that need to be addressed. Their data could be quite complex and at variance with what we know and do about stuttering in majority groups. High rates of clinical failures among minority group stutterers raise questions about whether we have overgeneralized our information to groups that have never been studied.
INTRODUCTION The problem of stuttering among minority group members who live in diverse cultural and linguistic environments may involve a number of issues that are quite different from those encountered among stutterers who are in the mainstream of their social milieu. The effects of specific cultures, cultural differences, of living in a diverse cultural environment, and of the burdens of bilingualism may be factors in the onset of the disorder as well as in the effectiveness of management strategies. As our societies rapidly become more heterogeneous, it becomes increasingly urgent that we raise questions about how generalizable to minority groups are our clinical experiences and research data. In the United States, our data are derived mostly from predominantly majority group populations. There is considerable evidence that stuttering is a multidimensional problem, involving emotional, behavioral, interpersonal, and social factors. It also involves linguistic, cognitive, psychologic, and physiologic variables as well. Many of these variables are directly related to the cultural and linguistic roots of the individuals who stutter. Address correspondence partment of Communication,
to George H. Shames, Ph.D., University of Pittsburgh, 1117 Cathedral of Learning, Pittsburgh, PA 15260.
0 1989 by Else&r Science Publishing Co., Inc. 655 Avenue of the Americas, New York. NY 10010
De-
67 0094-730X/89/$3.50
68
G. H. SHAMES
DEMOGRAPHICS OF STUTTERING Cultural anthropologists (Price, 1987) advise us that in order to describe and understand the effects of any culture, the first step is to develop appropriate demographic information about the phenomenon under study. Studies that focus on incidence, prevalence, definition, social attitudes, etc., provide information about the degree to which a phenomenon is a characteristic of a particular culture. The ready availability of such information provides clues as to whether the phenomenon has any social significance, and/or affects public health, educational, and administrative planning. It may also predict the productiveness of studying that phenomenon (i.e., stuttering) in that culture. However, any current lack of demographic information may also be an indication of economic and health priorities, or lack of education and training to recognize and look for the phenomenon in that culture. As a first step, the demography of a problem may be indicative of what to expect in the way of information about the problem. Stuttering generally is thought to affect about 1% of the population. However, in the United States, prevalence figures range from 0.3 to 2.1% in various specific populations of city school children. Outside the United States, the prevalence data for school children range from 0.55% in Czechoslovakia to 4.7% in the British West Indies (Bloodstein, 1987). There are large geographic areas where prevalence data are not available. It is obvious that we do not have enough prevalence data from all over the world to conclude that the 1% figure is an accurate representation of the prevalence of this problem in any particular locale. Such lack of information prevents us from knowing whether the problem exists at all, is not receiving much needed attention, or that a particular culture may contain some properties and information that may be invaluable if shared with the rest of the world. But, given the limited prevalence data that are available, stuttering is a major communication disorder that is quite complex and exists in many cultures and societies throughout the world. It has a long history of being resistant to alleviation since its earliest biblical notations. Stuttering is a problem that involves not only the speaker, but also his/ her community of listeners as well. Its basic definition, characteristics, social significance, and management are the functions and product of the society and culture in which it exists. The problem is not limited to those who carry the label of stutterer, but it also includes the stutterer’s cultural and linguistic community. The interactions between the stutterer and his community become even more complicated when that community is diverse, as is the case for many “hyphenated Americans,” (or hyphenated Britons, or hyphenated etc.).
STUTTERING: RFP FOR A CULTURAL PERSPECTIVE
IS STUTTERING UNIVERSAL ACROSS CULTURES? In the mid-1800s, George Catlin, a noted artist, observed that American Indians did not stutter. At least the ones he met, painted, and lived with for a while did not stutter. He observed numerous differences between them and the non-Indians who lived in the United States. He focused on the Indians’ comparatively better physical health. He thought that the reason the Indians were healthier was because they had developed different ways of breathing (through their noses rather than through their mouths). He published a book titled Shut Your Mouth and Save Yoltr Life, and although it did not become a best seller and serves no purpose here to evaluate the validity of his ideas, it is an illustration of one of the earliest attempts to look at stuttering cross-culturally (Catlin, 1891). Van Riper (1971) provides an excellent discussion of the universality of stuttering, noting the mention of stuttering in writings throughout the centuries -on clay tablets in Mesopotamia; by the Chinese poet Lao-tzu some 2,500 years ago; by Moses, Demosthemes, Balbus of the Roman Republic, Aviciena the Arabian poet of the late 900s A.D., and in modern times in the semantogenic theory of Wendell Johnson. Van Riper lists 14 European, nine Native American, two Pacific Island, ten Eastern, and six African cultures and languages where a word for stuttering exists. He goes on to say that stuttering, if it is a neurosis, is shared by diverse cultures, and is based on conflicts common to all human beings. If it is an atavistic regression to remain a suckling infant, this regression is common to all cultures. If it is learned behavior, then the necessary antecedents and consequences should also be “common to all races and times”; if it is excessive parental concern or high standards and parental misdiagnosis, these concerns and standards must be common to all cultures: and, finally, if it is established and maintained by secondary gains or other reinforcements, these, too, must be present in all people. This latter point of view suggests that cultures are the same around the world, insofar as the variables mentioned above are concerned, and, therefore, that data collected from any culture can be applied to any and all other cultures. However, it is one thing to say that stuttering is universal (which may still be a premature conclusion) and quite another thing to say that the particular stresses and cultural influences that result in stuttering are the same around the world. Comments by Kluckhohn (1954), an anthropologist, and Bloodstein’s (1987) summary of prevalence data strongly suggest that the large variations in prevalence from 0.55 percent to 4.7 percent can be interpreted as an indication that cultural influences are operative. Furthermore, data from the field of cultural anthropology about culture and the significant dimensions of culture reveal wide variations within and between countries relative to family structure; child-rearing practices;
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general and specific social and family attitudes; rules for verbal interactions; the definitions, significance, and management of handicaps; as well as variations in the properties of language and linguistic rules. Each of these could have a direct bearing on the definition, establishment, onset, maintenance. and treatment of stuttering. This point of view of “common to all cultures” may in part explain why there has been such little attention given to an individual’s culture or native language in bilingual speakers who stutter. STUTTERING
IN MINORITY
GROUPS
As a result of its multidimensionality, stuttering has received considerable attention from theorists, researchers, and clinicians, A large body of literature exists about those dimensions. However, our current data and understandings about stuttering stem overwhelmingly from the work going on in the United States, and primarily from various populations of stutterers who represent mainstream America (i.e., white, middle-class children; midwestern college students, etc.). As valuable as this work has been, our awareness of the cultural limitations of these studies should make us wonder whether there are significant gaps in our data, information, and comprehension of stuttering. Some serious questions can be raised about how generalizable our current information is. Let us consider a few of the issues and inquiries raised by this question about the generalizability of our data, from the standpoint of cultural differences and linguistic variables. Some of this discussion. although anecdotal, is based on a large number of personal contacts with professionals who work with stutterers throughout the world. Also, some of this discussion is based on a broad look at our recent published literature on the topic of stuttering, with a specific awareness of the adequacy of our attention to cultural and sociolinguistic issues. For those stutterers who find themselves in diverse cultural and linguistic enviornments, therapy itself could be an intercultural encounter. This may be especially true when clinical services are provided by professionals who are not trained or experienced in the client’s native culture and language. Taylor (1986) has characterized clinical management as a social occasion between the clinician and the client. Thus, therapy often becomes an intercultural collision of values, attitudes, expectations, and definitions. Leith (1986) has presented a number of illustrations of cultural issues in stuttering and of cultural clashes that can develop in the clinical relationship. They range from such things as Japanese males losing face by admitting fear, to communication between clinicians and families of stutterers from India being limited to the father (because he is the spokesperson for the family), to lack of eye contact and resistance to therapies involving deliberate, overt stuttering in U.S. blacks. Our conceptuali-
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zations of therapeutic transactions, our writings about therapy, and the principles, tactics and strategies that underly therapy have not included an acknowledgment of the impact of culture and language. As a result, there has been only limited impact of these issues on the thinking of the clinician or on the clinical interactions between the client and clinician. This lack of inclusion of cultural and linguistic effects is so generic and pervasive in most of our endeavors on the topic of stuttering that it is almost as though culture and language do not exist. To paraphrase Johnis not spoken son, “the professionals have no word for it” (1944)-what about, is not perceived, not attended to, and, therefore, does not exist nor occur. Of course, another interpretation could be that the significance of culture is denied perhaps because it is an invariant constant for all humans, as Van Riper has intimated. When my own clinical experiences and the experiences of others were examined, one simplistic question was asked: What kind of therapeutic results have you been experiencing with stutterers who are members of minority groups? This included Afro-Americans, Hispanics, Asian Americans, Native Americans, bilingual stutterers from all over the world (recent immigrants from Europe, Asia, the Middle East, the Caribbean, and the Pacific Ocean areas), and socially isolated groups in the United States, such as Cajuns, Amish, Mennenites, and Gullahs, etc. Many of these groups are isolated sometimes only by a few streets in our densely populated cities, trying to retain their native cultures and language while coping with and functioning in the mainstream of the United States. Some are in rural areas, or on reservations, coping in similar ways. The responses, from our colleagues, about their therapeutic results, ableit anecdotal, were generally consistent with my own. The results were usually poor. Coincidentally, the therapies ranged in focus from antiavoidance therapies, to fluency-enhancing therapies, to counseling therapies. Certainly the outcome of therapy can be due to numerous factors operating alone or in concert. Many are not under the control of the clinician. There is the client, his or her history, dynamics, and motivation. There are the client’s familly and/or the presence of a support system for him or her. There are the types and amounts of stress that the client lives with, day in and day out. There is the clinician, with his or her ability, commitment, technical skills, and caring attitude. And there is the therapy itself, its validity, comprehensiveness, and perhaps the client’s understanding of it. When all of these things coalesce in the right way, the outcome is generally good. When one of these types of factors does not fit neatly with the others, the outcome will probably not be as good. When one superimposes on these issues the burdens of simultaneously mastering more than one language and getting comfortable and functional in more than one culture, the problem becomes different and more complicated.
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As a further illustration of our experiences with minority groups and our need for more information, I have contacted large numbers of clinicians and researchers around the world to determine their interest in participating in an international meeting that will deal with the relationships among culture, language, and stuttering. There was unanimous and enthusiastic agreement to participate. Although it was not a scientific survey, these respondents, numbering more than 100 of the leading researchers, theorists, and clinicians in the world on stuttering, anthropology, and linguistics, communicated the message that there are questions to be asked, information to be shared, and answers to be developed on a worldwide level. Paralleling these clinical and anecdotal impressions from this international awareness of the value of looking at cultural and linguistic variables, I also looked at our research and research strategies on stuttering. A few basic questions were asked about our published literature. 1. Have there been considerations of cultural and linguistic variables as they may operate in stuttering? 2. What factors in our research on stuttering may have linguistic or cultural implications without being explicitly addressed? 3. Is it reasonable to generalize from mainstream U.S. cultural and linguistic data about stuttering to other cultures and languages and to minority groups, given what is known about variations in different populations? When one looks at the vast amount of literature on stuttering, the feeling of “benign neglect” of culture surfaces quickly. In the 1940s there was the literature concerned with the American Indians, primarily addressing Johnson’s semantogenic theory and the alleged absence of stuttering among American Indians (Johnson, 1944). Ultimately there was a public refutation of those data by Leljeblad (1967). On the international levels, much of the literature was about the prevalence of stuttering in Europe, Africa, and the Pacific Ocean areas, which addressed the issue of the universality of stuttering across cultures (Van Riper, 1971). There were some publications dealing with specific therapeutic approaches outside the United States. These came mainly from Canada, Australia, Africa, and Europe. A few articles on the physiology of stuttering came from Japan. In the United States, there has been a handful of studies on American blacks. One revealed that the sex ratio of stuttering was unlike the sex ratio in whites (2 : 1) males over female instead of the more traditional (4: 1) ratio (Goldman, 1967). Another study offered an explanation of covert-overt symptoms of stuttering in blacks (Leith and Mims, 1975). A third study on black athletes in Mississippi showed more word and phrase repetitions in black than in white nonstutterers during reading. There were no differences during conversation (Robinson and Crowe, 1987). There
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was one study of sociolinguistic nature on a Spanish-‘speaking bilingual stutterer (Bernstein and Benetiz, 1985). However, there have been a significant number of studies in the United States having either sociolinguistic or cultural implications without directly addressing these potentially relevant factors. Some of these are historically significant and are still having a current impact on our understanding, diagnosis, and treatment of the problem. For example, the literature on identification, attitudes about and definitions of stuttering (Ammons and Johnson, 1944; Bloodstein et al. 1952; Johnson, 1959; Lewis and Sherman, 1951; Wingate, 1964, on the social significance of stuttering Boehmler, 19.58; McDonald and Frick, 1954; Rosenberg and Curtiss, 1944), on stages of development (Bloodstein, 1960, 1961; Van Riper, 1971), on speech rate (Johnson, 1961), on linguistic loci of stuttering (Brown, 1945; Johnson and Brown, 1939), on language maturity (Davis, 1939, 1941), on parent-child interactions (Duncan, 1949; Egolf et al, 1972; Kasprisin-Burelli et al., 1972; Kinstler, 1961; Moncur, 1952), on verbal punishment procedures (Siegel, 1970), and on parental standards and goalsetting behavior (Goldman and Shames, 1964; Johnson et al., 1959) are but a few easy illustrations of categories of research that involved looking at issues and variables that may significantly vary from one culture to another, from one language to another, and from majority to minority groups within various countries. For example, the research data noted above can vary with such things as the differences in childrearing among Native Americans, with family structure and dynamics in Africa, with communal arrangements in Israel, with differences in syntax in the Spanish language, with the juncture pauses in French, with the naturalness of phonology and gutteral properties of German and Scandinavian languages, and with the social significance of a communication handicap among certain African and Asian groups. When we examine this research more closely, we see excellent designs that adhered to the principles of the scientific method. Unfortunately, in our attempt to isolate and manipulate independent variables, we may have shut ourselves off from important information. One such research control has involved the use of “homogeneous populations.” Such controls are necessary if we are to determine whether variations in a dependent variable are due to the independent variables under study or some extraneous factors. The result of this has been a very systematic (although benign) exclusion of minority groups from research populations. However, it is not the research control via homogeneous populations that is being criticized here, but rather the possible overgeneralization of our data and clinical experiences to minority groups who have never been studied. Our neglect has been in not considering replicating these studies on minority groups. We also appear to be offering clinical services to minority group populations based on experiences with mainstream populations.
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We need to look at native language and native cultures of minority groups. We need to make intercultural and interlinguistic comparisons about stuttering, its definition, its loci, its relationship to childrearing practices, and its social significance. But we must also study the problem from these standpoints in diverse cultural and diverse linguistic environments. The problem in the mainstream United States may be quite similar or different from the problem in mainstream Spanish-speaking Mexico or the problem in mainstream Chinese-speaking Taiwan. In turn, each of these may be different in different ways from the problem for Hispanics (Mexico or Puerto-Rican roots), or Asian Americans living in a diverse circumstance in California or New York, or Pakistanis living in London. Living in a diverse cultural and linguistic environment is quite different from living in a homogeneous cultural and linguistic environment, whether it be Mexico, Taiwan, Great Britain, or the United States. Each individual stutterer has his/her uniquely individual dynamics and coping mechanisms. We must retain our responsiveness and sensitivity to his/her individuality. But we must also expand our view to include the linguistic and cultural group forces that operate on that individual. No one operates totally outside of some form of society and culture. He/she may resist it, try to avoid it, try to accommodate it, or move away from it, but when this happens, he/she only moves into another culture, sometimes seeking asylum from one form of oppression only to find it in another form elsewhere.
CONCLUSION The communication problems of people in the mainstream of a society still need much attention and are still presenting significant challenges. However, these problems for minority populations are compounded in so many complex ways that they may require innovative and creative, multidimensional observations, and research strategies involving both laboratory and field studies. Some very basic questions have to be formulated and translated into research operations. The world has become very mobile. People are shifting into extremely diverse social circumstances. The United States has always been a diverse cultural and linguistic environment. In adapting to that circumstance, we have swung back and forth between the concept of “melting pot,” which focuses on assimilation and similarities between groups, and the concept which focuses on preserving ethnic cusof “retaining native identity,” toms, language, music, food, values, family dynamics, etc., and preserving the differences between groups. Whichever perspective one may embrace, our multicultural and multilinguistic environments have both enriching, as well as stressful, aspects. These stresses have to be understood, no matter what the presenting problem may be, including the man-
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agement of stuttering. It is tempting to say that these culturally and linguistically diverse environments have created new clinical populations, having new kinds of clinical problems, but carrying old labels that are met with old intervention strategies. However, that would not be totally accurate. These populations have been around for quite some time, as have their problems. Our awareness of them, our recognition of old and obsolete labels and inappropriate therapy strategies, and our sense of urgency for dealing with them is perhaps what is new. The research and clinical literature abounds with information about mainstream U.S. stutterers. It is dangerous to generalize this information to members of culturally different populations. Our high clinical failure
rate with minority group stutterers may be a testimony to this danger. From this, it follows that we need more research involving these diverse groups. In a similar vein, clinicians need to be attentive to cultural disparities in evaluating and treating stutterers who are members of minority groups. More should be written about how attention to any such differences impacted. upon the therapeutic process and its eventual outcome. These issues, for us, require freshly devised ways of educating ourselves and of conceptualizing and researching these problems. Indeed, we may need new kinds of basic education in other disciplines resulting in research and clinical teams, involving sociolinguists, cultural anthropologists, and multicultural and multilingual speech and language pathologists reasoning together to address these complex issues. This paper was developed while the author was on a sabbatical leave at Howard University, Washington, D.C., where he was a Post Doctoral Fellow on the university’s Leadership Personnel Preparation Project from the U.S. Office of Education. (grant no. GO08630085, project no. 029CH7022).
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Leith, W.E. Treating the stutterer with atypical cultural influences. In: The Atypical Stutterer, K.O. St. Louis, (ed.). Orlando, FL: Academic Press, 1986. Leith, W., and Mims, H. Cultural influences in the development and treatment of stuttering: A preliminary report on the black stutterer, Journal of Speech and Hearing Disorders,
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STUTTERING: AN RFP FOR A CULTURAL PERSPECTIVE GEORGE H. SHAMES University of Pittsburgh Stuttering has been the target of much attention from theorists and researchers as well as from clinicians. As a result, a large body of literature exists about its etiology, psychologic and physical properties, patterns of occurrence, measurement, and evaluation and management. In the United States, the overwhelming majority of data come from experiences with stutterers who are in the majority of mainstream America. Much of these data could vary across cultures and across languages. For minority group stutterers who live in diverse cultural and linguistic environments, there may be different burdens and stress that need to be addressed. Their data could be quite complex and at variance with what we know and do about stuttering in majority groups. High rates of clinical failures among minority group stutterers raise questions about whether we have overgeneralized our information to groups that have never been studied.
INTRODUCTION The problem of stuttering among minority group members who live in diverse cultural and linguistic environments may involve a number of issues that are quite different from those encountered among stutterers who are in the mainstream of their social milieu. The effects of specific cultures, cultural differences, of living in a diverse cultural environment, and of the burdens of bilingualism may be factors in the onset of the disorder as well as in the effectiveness of management strategies. As our societies rapidly become more heterogeneous, it becomes increasingly urgent that we raise questions about how generalizable to minority groups are our clinical experiences and research data. In the United States, our data are derived mostly from predominantly majority group populations. There is considerable evidence that stuttering is a multidimensional problem, involving emotional, behavioral, interpersonal, and social factors. It also involves linguistic, cognitive, psychologic, and physiologic variables as well. Many of these variables are directly related to the cultural and linguistic roots of the individuals who stutter. Address correspondence partment of Communication,
to George H. Shames, Ph.D., University of Pittsburgh, 1117 Cathedral of Learning, Pittsburgh, PA 15260.
0 1989 by Else&r Science Publishing Co., Inc. 655 Avenue of the Americas, New York. NY 10010
De-
67 0094-730X/89/$3.50
68
G. H. SHAMES
DEMOGRAPHICS OF STUTTERING Cultural anthropologists (Price, 1987) advise us that in order to describe and understand the effects of any culture, the first step is to develop appropriate demographic information about the phenomenon under study. Studies that focus on incidence, prevalence, definition, social attitudes, etc., provide information about the degree to which a phenomenon is a characteristic of a particular culture. The ready availability of such information provides clues as to whether the phenomenon has any social significance, and/or affects public health, educational, and administrative planning. It may also predict the productiveness of studying that phenomenon (i.e., stuttering) in that culture. However, any current lack of demographic information may also be an indication of economic and health priorities, or lack of education and training to recognize and look for the phenomenon in that culture. As a first step, the demography of a problem may be indicative of what to expect in the way of information about the problem. Stuttering generally is thought to affect about 1% of the population. However, in the United States, prevalence figures range from 0.3 to 2.1% in various specific populations of city school children. Outside the United States, the prevalence data for school children range from 0.55% in Czechoslovakia to 4.7% in the British West Indies (Bloodstein, 1987). There are large geographic areas where prevalence data are not available. It is obvious that we do not have enough prevalence data from all over the world to conclude that the 1% figure is an accurate representation of the prevalence of this problem in any particular locale. Such lack of information prevents us from knowing whether the problem exists at all, is not receiving much needed attention, or that a particular culture may contain some properties and information that may be invaluable if shared with the rest of the world. But, given the limited prevalence data that are available, stuttering is a major communication disorder that is quite complex and exists in many cultures and societies throughout the world. It has a long history of being resistant to alleviation since its earliest biblical notations. Stuttering is a problem that involves not only the speaker, but also his/ her community of listeners as well. Its basic definition, characteristics, social significance, and management are the functions and product of the society and culture in which it exists. The problem is not limited to those who carry the label of stutterer, but it also includes the stutterer’s cultural and linguistic community. The interactions between the stutterer and his community become even more complicated when that community is diverse, as is the case for many “hyphenated Americans,” (or hyphenated Britons, or hyphenated etc.).
STUTTERING: RFP FOR A CULTURAL PERSPECTIVE
IS STUTTERING UNIVERSAL ACROSS CULTURES? In the mid-1800s, George Catlin, a noted artist, observed that American Indians did not stutter. At least the ones he met, painted, and lived with for a while did not stutter. He observed numerous differences between them and the non-Indians who lived in the United States. He focused on the Indians’ comparatively better physical health. He thought that the reason the Indians were healthier was because they had developed different ways of breathing (through their noses rather than through their mouths). He published a book titled Shut Your Mouth and Save Yoltr Life, and although it did not become a best seller and serves no purpose here to evaluate the validity of his ideas, it is an illustration of one of the earliest attempts to look at stuttering cross-culturally (Catlin, 1891). Van Riper (1971) provides an excellent discussion of the universality of stuttering, noting the mention of stuttering in writings throughout the centuries -on clay tablets in Mesopotamia; by the Chinese poet Lao-tzu some 2,500 years ago; by Moses, Demosthemes, Balbus of the Roman Republic, Aviciena the Arabian poet of the late 900s A.D., and in modern times in the semantogenic theory of Wendell Johnson. Van Riper lists 14 European, nine Native American, two Pacific Island, ten Eastern, and six African cultures and languages where a word for stuttering exists. He goes on to say that stuttering, if it is a neurosis, is shared by diverse cultures, and is based on conflicts common to all human beings. If it is an atavistic regression to remain a suckling infant, this regression is common to all cultures. If it is learned behavior, then the necessary antecedents and consequences should also be “common to all races and times”; if it is excessive parental concern or high standards and parental misdiagnosis, these concerns and standards must be common to all cultures: and, finally, if it is established and maintained by secondary gains or other reinforcements, these, too, must be present in all people. This latter point of view suggests that cultures are the same around the world, insofar as the variables mentioned above are concerned, and, therefore, that data collected from any culture can be applied to any and all other cultures. However, it is one thing to say that stuttering is universal (which may still be a premature conclusion) and quite another thing to say that the particular stresses and cultural influences that result in stuttering are the same around the world. Comments by Kluckhohn (1954), an anthropologist, and Bloodstein’s (1987) summary of prevalence data strongly suggest that the large variations in prevalence from 0.55 percent to 4.7 percent can be interpreted as an indication that cultural influences are operative. Furthermore, data from the field of cultural anthropology about culture and the significant dimensions of culture reveal wide variations within and between countries relative to family structure; child-rearing practices;
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general and specific social and family attitudes; rules for verbal interactions; the definitions, significance, and management of handicaps; as well as variations in the properties of language and linguistic rules. Each of these could have a direct bearing on the definition, establishment, onset, maintenance. and treatment of stuttering. This point of view of “common to all cultures” may in part explain why there has been such little attention given to an individual’s culture or native language in bilingual speakers who stutter. STUTTERING
IN MINORITY
GROUPS
As a result of its multidimensionality, stuttering has received considerable attention from theorists, researchers, and clinicians, A large body of literature exists about those dimensions. However, our current data and understandings about stuttering stem overwhelmingly from the work going on in the United States, and primarily from various populations of stutterers who represent mainstream America (i.e., white, middle-class children; midwestern college students, etc.). As valuable as this work has been, our awareness of the cultural limitations of these studies should make us wonder whether there are significant gaps in our data, information, and comprehension of stuttering. Some serious questions can be raised about how generalizable our current information is. Let us consider a few of the issues and inquiries raised by this question about the generalizability of our data, from the standpoint of cultural differences and linguistic variables. Some of this discussion. although anecdotal, is based on a large number of personal contacts with professionals who work with stutterers throughout the world. Also, some of this discussion is based on a broad look at our recent published literature on the topic of stuttering, with a specific awareness of the adequacy of our attention to cultural and sociolinguistic issues. For those stutterers who find themselves in diverse cultural and linguistic enviornments, therapy itself could be an intercultural encounter. This may be especially true when clinical services are provided by professionals who are not trained or experienced in the client’s native culture and language. Taylor (1986) has characterized clinical management as a social occasion between the clinician and the client. Thus, therapy often becomes an intercultural collision of values, attitudes, expectations, and definitions. Leith (1986) has presented a number of illustrations of cultural issues in stuttering and of cultural clashes that can develop in the clinical relationship. They range from such things as Japanese males losing face by admitting fear, to communication between clinicians and families of stutterers from India being limited to the father (because he is the spokesperson for the family), to lack of eye contact and resistance to therapies involving deliberate, overt stuttering in U.S. blacks. Our conceptuali-
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zations of therapeutic transactions, our writings about therapy, and the principles, tactics and strategies that underly therapy have not included an acknowledgment of the impact of culture and language. As a result, there has been only limited impact of these issues on the thinking of the clinician or on the clinical interactions between the client and clinician. This lack of inclusion of cultural and linguistic effects is so generic and pervasive in most of our endeavors on the topic of stuttering that it is almost as though culture and language do not exist. To paraphrase Johnis not spoken son, “the professionals have no word for it” (1944)-what about, is not perceived, not attended to, and, therefore, does not exist nor occur. Of course, another interpretation could be that the significance of culture is denied perhaps because it is an invariant constant for all humans, as Van Riper has intimated. When my own clinical experiences and the experiences of others were examined, one simplistic question was asked: What kind of therapeutic results have you been experiencing with stutterers who are members of minority groups? This included Afro-Americans, Hispanics, Asian Americans, Native Americans, bilingual stutterers from all over the world (recent immigrants from Europe, Asia, the Middle East, the Caribbean, and the Pacific Ocean areas), and socially isolated groups in the United States, such as Cajuns, Amish, Mennenites, and Gullahs, etc. Many of these groups are isolated sometimes only by a few streets in our densely populated cities, trying to retain their native cultures and language while coping with and functioning in the mainstream of the United States. Some are in rural areas, or on reservations, coping in similar ways. The responses, from our colleagues, about their therapeutic results, ableit anecdotal, were generally consistent with my own. The results were usually poor. Coincidentally, the therapies ranged in focus from antiavoidance therapies, to fluency-enhancing therapies, to counseling therapies. Certainly the outcome of therapy can be due to numerous factors operating alone or in concert. Many are not under the control of the clinician. There is the client, his or her history, dynamics, and motivation. There are the client’s familly and/or the presence of a support system for him or her. There are the types and amounts of stress that the client lives with, day in and day out. There is the clinician, with his or her ability, commitment, technical skills, and caring attitude. And there is the therapy itself, its validity, comprehensiveness, and perhaps the client’s understanding of it. When all of these things coalesce in the right way, the outcome is generally good. When one of these types of factors does not fit neatly with the others, the outcome will probably not be as good. When one superimposes on these issues the burdens of simultaneously mastering more than one language and getting comfortable and functional in more than one culture, the problem becomes different and more complicated.
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As a further illustration of our experiences with minority groups and our need for more information, I have contacted large numbers of clinicians and researchers around the world to determine their interest in participating in an international meeting that will deal with the relationships among culture, language, and stuttering. There was unanimous and enthusiastic agreement to participate. Although it was not a scientific survey, these respondents, numbering more than 100 of the leading researchers, theorists, and clinicians in the world on stuttering, anthropology, and linguistics, communicated the message that there are questions to be asked, information to be shared, and answers to be developed on a worldwide level. Paralleling these clinical and anecdotal impressions from this international awareness of the value of looking at cultural and linguistic variables, I also looked at our research and research strategies on stuttering. A few basic questions were asked about our published literature. 1. Have there been considerations of cultural and linguistic variables as they may operate in stuttering? 2. What factors in our research on stuttering may have linguistic or cultural implications without being explicitly addressed? 3. Is it reasonable to generalize from mainstream U.S. cultural and linguistic data about stuttering to other cultures and languages and to minority groups, given what is known about variations in different populations? When one looks at the vast amount of literature on stuttering, the feeling of “benign neglect” of culture surfaces quickly. In the 1940s there was the literature concerned with the American Indians, primarily addressing Johnson’s semantogenic theory and the alleged absence of stuttering among American Indians (Johnson, 1944). Ultimately there was a public refutation of those data by Leljeblad (1967). On the international levels, much of the literature was about the prevalence of stuttering in Europe, Africa, and the Pacific Ocean areas, which addressed the issue of the universality of stuttering across cultures (Van Riper, 1971). There were some publications dealing with specific therapeutic approaches outside the United States. These came mainly from Canada, Australia, Africa, and Europe. A few articles on the physiology of stuttering came from Japan. In the United States, there has been a handful of studies on American blacks. One revealed that the sex ratio of stuttering was unlike the sex ratio in whites (2 : 1) males over female instead of the more traditional (4: 1) ratio (Goldman, 1967). Another study offered an explanation of covert-overt symptoms of stuttering in blacks (Leith and Mims, 1975). A third study on black athletes in Mississippi showed more word and phrase repetitions in black than in white nonstutterers during reading. There were no differences during conversation (Robinson and Crowe, 1987). There
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was one study of sociolinguistic nature on a Spanish-‘speaking bilingual stutterer (Bernstein and Benetiz, 1985). However, there have been a significant number of studies in the United States having either sociolinguistic or cultural implications without directly addressing these potentially relevant factors. Some of these are historically significant and are still having a current impact on our understanding, diagnosis, and treatment of the problem. For example, the literature on identification, attitudes about and definitions of stuttering (Ammons and Johnson, 1944; Bloodstein et al. 1952; Johnson, 1959; Lewis and Sherman, 1951; Wingate, 1964, on the social significance of stuttering Boehmler, 19.58; McDonald and Frick, 1954; Rosenberg and Curtiss, 1944), on stages of development (Bloodstein, 1960, 1961; Van Riper, 1971), on speech rate (Johnson, 1961), on linguistic loci of stuttering (Brown, 1945; Johnson and Brown, 1939), on language maturity (Davis, 1939, 1941), on parent-child interactions (Duncan, 1949; Egolf et al, 1972; Kasprisin-Burelli et al., 1972; Kinstler, 1961; Moncur, 1952), on verbal punishment procedures (Siegel, 1970), and on parental standards and goalsetting behavior (Goldman and Shames, 1964; Johnson et al., 1959) are but a few easy illustrations of categories of research that involved looking at issues and variables that may significantly vary from one culture to another, from one language to another, and from majority to minority groups within various countries. For example, the research data noted above can vary with such things as the differences in childrearing among Native Americans, with family structure and dynamics in Africa, with communal arrangements in Israel, with differences in syntax in the Spanish language, with the juncture pauses in French, with the naturalness of phonology and gutteral properties of German and Scandinavian languages, and with the social significance of a communication handicap among certain African and Asian groups. When we examine this research more closely, we see excellent designs that adhered to the principles of the scientific method. Unfortunately, in our attempt to isolate and manipulate independent variables, we may have shut ourselves off from important information. One such research control has involved the use of “homogeneous populations.” Such controls are necessary if we are to determine whether variations in a dependent variable are due to the independent variables under study or some extraneous factors. The result of this has been a very systematic (although benign) exclusion of minority groups from research populations. However, it is not the research control via homogeneous populations that is being criticized here, but rather the possible overgeneralization of our data and clinical experiences to minority groups who have never been studied. Our neglect has been in not considering replicating these studies on minority groups. We also appear to be offering clinical services to minority group populations based on experiences with mainstream populations.
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We need to look at native language and native cultures of minority groups. We need to make intercultural and interlinguistic comparisons about stuttering, its definition, its loci, its relationship to childrearing practices, and its social significance. But we must also study the problem from these standpoints in diverse cultural and diverse linguistic environments. The problem in the mainstream United States may be quite similar or different from the problem in mainstream Spanish-speaking Mexico or the problem in mainstream Chinese-speaking Taiwan. In turn, each of these may be different in different ways from the problem for Hispanics (Mexico or Puerto-Rican roots), or Asian Americans living in a diverse circumstance in California or New York, or Pakistanis living in London. Living in a diverse cultural and linguistic environment is quite different from living in a homogeneous cultural and linguistic environment, whether it be Mexico, Taiwan, Great Britain, or the United States. Each individual stutterer has his/her uniquely individual dynamics and coping mechanisms. We must retain our responsiveness and sensitivity to his/her individuality. But we must also expand our view to include the linguistic and cultural group forces that operate on that individual. No one operates totally outside of some form of society and culture. He/she may resist it, try to avoid it, try to accommodate it, or move away from it, but when this happens, he/she only moves into another culture, sometimes seeking asylum from one form of oppression only to find it in another form elsewhere.
CONCLUSION The communication problems of people in the mainstream of a society still need much attention and are still presenting significant challenges. However, these problems for minority populations are compounded in so many complex ways that they may require innovative and creative, multidimensional observations, and research strategies involving both laboratory and field studies. Some very basic questions have to be formulated and translated into research operations. The world has become very mobile. People are shifting into extremely diverse social circumstances. The United States has always been a diverse cultural and linguistic environment. In adapting to that circumstance, we have swung back and forth between the concept of “melting pot,” which focuses on assimilation and similarities between groups, and the concept which focuses on preserving ethnic cusof “retaining native identity,” toms, language, music, food, values, family dynamics, etc., and preserving the differences between groups. Whichever perspective one may embrace, our multicultural and multilinguistic environments have both enriching, as well as stressful, aspects. These stresses have to be understood, no matter what the presenting problem may be, including the man-
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agement of stuttering. It is tempting to say that these culturally and linguistically diverse environments have created new clinical populations, having new kinds of clinical problems, but carrying old labels that are met with old intervention strategies. However, that would not be totally accurate. These populations have been around for quite some time, as have their problems. Our awareness of them, our recognition of old and obsolete labels and inappropriate therapy strategies, and our sense of urgency for dealing with them is perhaps what is new. The research and clinical literature abounds with information about mainstream U.S. stutterers. It is dangerous to generalize this information to members of culturally different populations. Our high clinical failure
rate with minority group stutterers may be a testimony to this danger. From this, it follows that we need more research involving these diverse groups. In a similar vein, clinicians need to be attentive to cultural disparities in evaluating and treating stutterers who are members of minority groups. More should be written about how attention to any such differences impacted. upon the therapeutic process and its eventual outcome. These issues, for us, require freshly devised ways of educating ourselves and of conceptualizing and researching these problems. Indeed, we may need new kinds of basic education in other disciplines resulting in research and clinical teams, involving sociolinguists, cultural anthropologists, and multicultural and multilingual speech and language pathologists reasoning together to address these complex issues. This paper was developed while the author was on a sabbatical leave at Howard University, Washington, D.C., where he was a Post Doctoral Fellow on the university’s Leadership Personnel Preparation Project from the U.S. Office of Education. (grant no. GO08630085, project no. 029CH7022).
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